Gay, bisexual, and other men who have sex with men: time to end the fixation with HIVBMJ 2016; 354 doi: https://doi.org/10.1136/bmj.i4739 (Published 02 September 2016) Cite this as: BMJ 2016;354:i4739
- M Pakianathan, consultant in HIV and sexual health,
- N Daley, foundation year 2 doctor,
- A Hegazi, consultant in HIV and sexual health
- Courtyard Clinic, Wandsworth Integrated Sexual Health, St George’s University Hospital Foundation Trust, London, UK
- Correspondence to: M Pakianathan
HIV has been inextricably linked with gay men’s health since the term “gay related immune deficiency” was first used to refer to AIDS in the early 1980s. Today, the collective emphasis of health interventions targeted at gay, bisexual, and other men who have sex with men remains focused on preventing sexually transmitted infection, to the extent that absence of HIV has come to be regarded almost synonymously with gay men’s health.
Beyond HIV, health disparities in this group of men encompass a range of physical conditions, including asthma, cardiovascular disease, and cancer.1 They are also more likely to experience physical disability and to report poorer self rated health.1 Determinants of these differences have received limited public and medical attention and remain relatively unstudied. Further inequality is driven by an unwillingness to seek medical care or disclose sexuality to healthcare providers because of perceived negative healthcare experiences.2 Demographic and socioeconomic factors also contribute independently to health disparities within this diverse population.3
It is in sexual health, mental health, smoking, and alcohol and recreational drug use that the inequalities remain most apparent. The lesbian, gay, bisexual, and transsexual companion document to the Public Health Outcomes Framework and Public Health England’s draft strategy to promote the health and wellbeing of gay, bisexual, and other men who have sex with men highlight the synergy between these inequalities (described as a syndemic) and emphasise a holistic approach.4 5
Decriminalisation and anti-discrimination legislation remain priorities globally. In 75 countries men who have sex with men risk arrest, conviction, and violence because of punitive laws.6 A legacy of hostility remains in UK society. The advocacy group Stonewall reported that more than half of gay and bisexual UK school pupils experienced homophobic bullying.4 Reluctance to “come out” can create stress predisposing to poorer mental health.7 Gay men also remain victims of hate crime and may be abused for public displays of affection.6
The premise that homosexuality is immoral and a mental illness (declassified by the World Health Organization only in 1992) has given rise to conversion therapies associated with additional harms and stigma. The minority stress hypothesis postulates that the stigma, prejudice, and discrimination experienced by minority groups drives mental and physical health problems.7 Internalised homonegativity—when negative societal attitudes towards same sex behaviours are integrated into the value system and self concept of some gay and bisexual men—correlates with depression, anxiety symptoms, substance use disorders, and suicidal ideation.1 In fact, compared with heterosexuals, men who have sex with men are around 2.5 times more likely to experience a mental disorder at any point in their lifetime and six times more likely to have attempted suicide.7 8 Problematic alcohol use and recreational drug use and dependency are also higher.4
Chemsex, the sexualised use of mephedrone, crystallised methamphetamine, and γ-hydroxybutyrate (GHB) or γ-butyrolactone (GBL), has recently been increasingly reported.9 It is associated with anal sex, other unintended risk behaviours, HIV, and sexually transmitted infections.9 10 Understanding the motivation for drug use, chemsex, or any potentially self harming choice is key. Low self esteem may facilitate high risk sexual behaviour and substance use through its association with anxiety.11 In qualitative studies, some men who have sex with men report using risky sex to improve confidence or to ameliorate negative feelings such as loneliness, isolation, low self esteem, internalised sexual stigma, or HIV stigma.9 12 We need a better understanding of the biological, psychological, social, and cultural motivation factors for risk taking behaviours and participation in chemsex as well as the broader social, legal, and health consequences of chemsex.
Transforming societal attitudes and tackling abuse and bullying in schools remain priorities. Sex and relationship education curriculums should become more inclusive, and we need to create safe environments for young men to explore their sexuality. Reporting of sexual orientation, already routinely done in sexual health services, should be extended to primary care, mental health, and substance use services as a first step to measuring the extent of need. Health professionals should receive cultural competency training to better serve the needs of this population. There is also a need to challenge cultural norms within gay communities and improve emotional literacy—understanding not only the consequences of risk taking but its motivations and triggers. The agendas of commissioners, policy makers, and national level funders, researchers, and the voluntary sector should be reoriented to raise aspirations to tackle all health inequalities among gay, bisexual, and other men who have sex with men, not just being free of HIV.
The narrow HIV focused prevention model should be abandoned. An approach that promotes health and wellbeing and takes specific action on the wider inequalities facing this population is more likely to achieve sustainable results. It also enables the inclusion of men who are already HIV positive. Harnessing the creativity and resourcefulness within gay and bisexual communities will be vital to inform and shape a policy that enables much needed system-wide transformation.
Competing interests: We have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.
Provenance and peer review: Not commissioned; externally peer reviewed